Q: When a bilateral pulmonary artery thrombectomy is performed for a saddle embolus seen on CTA chest, what are the appropriate codes to report?
A: Components that can potentially be coded, assuming appropriate documentation in the procedure report, include primary arterial mechanical thrombectomy (37184-50), catheter placement into the right and left pulmonary arteries (36014-RT and 36014-LT), ultrasound guidance (+76937) and moderate sedation (99152, 99153).
The pulmonary arteries are classified under arterial thrombectomy and are coded with the primary percutaneous transluminal mechanical thrombectomy, non-coronary and non-intracranial code (37184). This code includes fluoroscopic guidance and any pharmacologic thrombolytic injections, as well as post-thrombectomy pulmonary angiography and pressure measurements, which are not separately reportable.
Thrombectomy of a saddle embolus generally requires removal of thrombus from both the right and left pulmonary arteries. In such cases, it is appropriate to report 37184 with modifier 50 for a bilateral procedure. If the embolus extends from the right pulmonary artery into a segmental branch, this is still reported as 37184 alone. If an additional distinct thrombus requires treatment, 37185 may be reportable. Conversely, if the saddle thrombus is completely removed with catheterization and aspiration of only one pulmonary artery, then 37184 is reported without modifier 50. Importantly, this code is reported once per vessel, regardless of the number of aspirations or “passes.” For example, four aspirations from the right pulmonary artery and three aspirations from the left pulmonary artery are still only coded as 37184 with modifier 50 for a bilateral procedure.
Catheter placement and radiological supervision and interpretation (RS&I) codes may also be reported if documentation supports them. The right and left pulmonary arteries are considered separate vascular families and each represents a first-order catheterization, reported with 36014-RT and 36014-LT. Note that catheter placement in the main pulmonary artery and/or right atrium is already accounted for in the codes for catheterizing the right and left pulmonary artery and not separately reportable.
In this example, the embolus was diagnosed on CTA chest, so RS&I codes should not be reported. However, if the CTA was inadequate and diagnostic angiography was required, or if there was a change in clinical status necessitating further diagnostic evaluation, then the appropriate RS&I codes may be reported.
If ultrasound-guided vascular access is performed and an image is documented and stored in PACS, add-on code 76937 is appropriate. If moderate sedation is administered, report 99152 for the initial 15 minutes and 99153 for each additional 15 minutes.
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